20200117Inland Cellular LLC Form 555.pdf

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Annual Lifeline Eligibte Telecommunications Carrier Certification Form All carriers must complete all or portions
of all sections Form must be submitted to USAC and filed with the Federal Communications Commission
IMPORTANT: PLEASE READ INSTRUCTIONS FIRST
Deadline: Ianuary 31a (Annually)
Does the reporting company have affiliated ETCs?Yes E[ No El
Provide a list ofall ETC| that ate qllliated with the reponing ETC, using poge 4 qnd additional sheets ifnecessary. Afiliation shall be
deter ined in accorda ce vith Section 3(2) ofthe Com unicalions Act, Thot Section dejites "alJiliate " as "a penoh thdt (directly or indirectv
owns or controls, is owned or controlled by, or is under common ownership or contolvith, anolher Wrson." 47 U.S.C. $ 153(2). See also 47
c.F.R. I 76.t200.
Affiliated ETC's SAC Affiliated El-C's Name
(-zm
C)\,m eimqao(3
ACU)o
475007 143037458
Study Area Code (SAC) Service Provider Identification Number (SPIN)
(An Eligible Telecommunications Carier (ETC) rnusl proide a cefiification form for erch SAC thtough which it provides Lifeline service),
ID
State ETC Name
lnland Cellular Telephone Company
DBA, Marketing, or Other Branding Name
(lfsane as ETC rutu4 list 'N/A ' Do not leave blonk)
Holding Company Name
(lfsane as ETC none, list "N/4" Do not leave blahk)
2019
Recertification Year
N/A
lnland Cellular LLC
1
ETCs Subject to the Non-Usrge Requirements
All ETCs must complele lhe oppropiate check-boL ETCI lhat do not assess and collecl o monthly Iee from their Lifeline subscribers are subjecl
to the fion-usaEe requirements. ETCS subject to the non-usage rcquirements ,nust indicate the number ofsubscihers de-enrolled by month in
Section 4. ETCI that only asess alee but do not collect suchfees are ruhject to the non-usage requiremenls ond must also indicate the number of
subscibers de-enrolled by month.
Is the ETC subject to the non-usage r€quirements? Yes @ No Eil
lfyes, record the number ofsubsciben de-enrolledJbr non-rsage by mohth in Block I belov'.
P a
Month Subscribers De-Enrolled lbr Non-Usage
January 0
February 0
March 0
April 0
May 0
June 0
July 0
Auzust 0
September 0
October 0
November 0
December 0
Total Subscribers 0
For purposes ofthis filing, an officer is an occupant ofa position listed in the article of incorporation, articles of formation,
or other similar legal document. An officer is a person who occupies a position specified in the corporate byJaws (or
partnership agreement), and would t)?ically be president, vice president for operations, vice president for finance,
comptroller, treasurer, or a comparable position. Ifthe filer is a sole proprietorship, the owner must sig! the certification.
Initial Certificatiott ,llt ercs must comptete rhis section
I certiry that the company listed above has certification procedures in place to:
A) Review income and program-based eligibility documentation prior to euolling a consumer in the Lifeline program, and
that, to the best of my knowledge, the company was presented with documentation of each consumer's household
income and/or program-based eligibility prior to his or her enrollment in Lifeline; and./or
B) Confirm consumer eligibility by relying upon access to a state database and./or notice ofeligibility from the state
Lifeline admilistrator prior to enrolling a consumer in the Lifeline program.
I am an officer of the company named above. I am authorized to make this certification for the Study Area Code listed
above.
NWInitial
)
Minimum Scrvice Level
l;%f.y that the company listed above is in compliance with the minimum service levels set forth in the 47 CFR Section
I am an officer of the company named above. I am authorized to make this certification for the SACs listed above.
Initiat NW
Repon the number of Lifeline subscribers due for recertification by month (January-Decamber)A. Subscribers eligible for r€cenificatioo by anniversary monthB, Subscribers dc-cnrolled prior to recertification atternptsC. Total number of subscribers ETC is responsible for reccdrying (A-B)
Recertification Methods
Strte of federal drtrbeseD. Subscribers rclertified thmugh ETC access to state or federal database by aoniversary month
the number ol el subscribcrs vmlicd access to a state or fedeml datahase,
E. Name ofthe data source(s) used to verifu consumer eligibility:
ETC Direct ContrctF. Subscribers contacted by ETC dircctly to rec€niry (You may also us€ this section to rcport subsqiber initiat€d recertifications),
the numbcr of Lilbline subscribers the ETC contacted to obtain rcceiification of
G. Subscribe6 who failed to recertily through ETC direct oureach attempt
R the number of Lif'eline subscribers dc-c.rlroll€d due to sc to th€ F:-It 's outreach attem
Jan Feb lll ar Apr Nliy Jun Jul Aug sep Oct Nov Dec Year
Totrl
0 0 0 0 0 0 0 0 0 0 0 0 0
B-0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Fcb )l sr t\,t ay Jun Jul Aug sep Oct Dec Yea r
Total
D 0 0 0 0 0 0 0 0 0 0 0 0
JunJanFebMarAprI'l sy Jul Aug sep Oct Nov Dec Year
Totrl
F 0 0 0 000 0 0 0 0 0 0 0
lI ar Ap.I\l ay JunFeb Jul Aug sep Oct Dec Year
'l otal
0 0 0 0 0 0 0 0 0 0 0 0 0
3
Annual Recertification
Do not leave empty block. If an ETC has nothing to report in a block, enter a zero,
C.
Apr
I 0
I
Jan
G.
H. Subscribers who recertifie'd through ETC direct outreach attempt
lhe number ofLifeline subscribers that recertificd E IC s outrcach
Thlrd PartyI. Subscribers u,hose eligibility was reviewed by state administrator, third party adminismtor, or USAC
the number of Lifeline subscribes contactdl by a state administrator, third administralor, or USAC for thc of rcccfl ilication.
J. Name ofthird party administrator used to verif, subscriber eligihiliry:
K. Subscribers de-cnrollcd as a result ofa thi.d party recenification attempt
the number of subscribeni as a rcsult of sc ro outrcach From a stale adminNlEror, Grrd administrator, or USAC
L. Subscribers \rho recertified through a state administrator. third parry administrator. or USAC's recenification effon
thc numbo of subscribcrs dlat recertified throueh a from a slate administrator third administator. or USAC
Certification:
Recertifi cation Method: Drtsbose
I certify that the company listed above has procedures in place to recertify consumer eligibility by relying on a database. I
am an officer ofthe company named above. I am authorized to make this certification for the SAC(s) listed above.
Initial NW
4
,lun Jul Aug sep Oct Nov Dec Year
'fotalJanFebNlarAprN'l ay.'
0 0 0 0 0 0H00000
Jrn Feb IIar Apr Ms],lu n Jul Aug sep Oct Nov Dec Year
Total
I 0 0 0 0 0 0 0 0 0 0 0 0 0
Jan Feb llt nr Apr Ma)sep Oct Dec Year
Tolsl
0 0 0 0 0 0 0 0 0 0 0 0 0K
.l sn Feb Mrr Apr Nl ay .lun Jul Aug sep Ocl Dec Year
Totsl
0 0 0 0 0 0 0 0 0 0L.0 0 0
0 0
l.tun lr,, I
n,*
Recertification Method: ETC
I certiry that the company listed above has procedures in place to receftiry the continued eligibility of all of its Lifeline
subscribers, and that, to the b€st ofmy knowledge, the company obtained signed certifications from all subscribers attesting
to their continuing eligibility for Lifeline. I am an officer of the company named above. I am authorized to make this
certification for the SAC(s) Iisted above.
Initial NW
Recertification Method: Third Party
I certi8/ that the company listed above has procedures in place to recertifo consumer eligibility by relying on an
administrator. I am an officer of the company named above. I am authorized to make this certification for the SAC(s)
listed above.
Initial NW
No Subscribers
I certify that my company did not claim federal low income support for any Lifeline subscribers for the current Form 555
data year. I am an offrcer ofthe company named above. I am authorized to make this certification for the SAC listed
above.
Initial NW
M = (G+K)N = (D+F+D o = M^i*ro0
Totsl number ofsubscribers de-enrolled as
r result of rece.tification
Total number ofsubscrlbers ETC is
responsible for recertifying
Percent of subrcrlbers due for
recertlllcetion who were de'€trrolled
0 0 0.0%
Signature Block
By signing below, I certiry that the company listed above is in compliance with all federal Lifeline certification
procedures. I am an officer ofthe company named above. I am authorized to make this certification for the Study
Area Code (SAC) listed above.
Signed,
Nathan R. Weis Nathan R. Weis
Signature ofOtlicq
[e-mail]
Printed Name and Title ofOffrcer
Jan 16,2020
Email Address of Oftrcer
Mike Bly
Person Completing This Certification Form
Dalc
2087980245
Contact Phone Number
5
Affiliated ETCs
SAC Name
529003 lnland Cellular LLC
529004 lnland Cellular LLC
6